1. Field of the Invention
The present invention relates a method and improved alert system for medicine containers. In particular, the present invention relates to a method and improved alert system for medicine that when applied, will warn the preparer of the medication of the high risk nature of the pharmaceutical product and distinguish such medicine products with sound-alike and look-alike names.
2. Description of the Background Art
In preparing medication, the preparer needs to be alert for sound-alike and look-alike drug names and packages which can lead preparers such as physicians, pharmacists, nurses and other health care professionals to unintended interchanges of drugs which can result in patient injury or death. The existing medication-use system is flawed because its safety depends on human perfection. Simplicity, standardization, differentiation, lack of duplication and unambiguous communication are human factor concepts that are relevant to the medication-use process. These principles have often been ignored in drug naming, labeling, and packaging. Instead, current methods are based on long-standing commercial considerations and bureaucratic procedures. Although a variety of private-sector organizations have called for reforms in drug naming, labeling, and packaging standards, the problem remains.
Look-alike drug names and packages increase the risk of unintended interchanges of drugs that can result in serious complications, even death. Labels that are hard to read or confusing can also contribute to errors. Drug names appearing on labeling may be in small print. Two vials that appear to be virtually identical (except for the drug name) may contain vastly different drugs. If one of those vials contains a high-alert medication, the consequence of confusion could be tragic. One such example was recently printed in the Institute for Safe Medication Practices (ISMP) Medication Safety Alert Newsletter. In a pediatric ICU, a respiratory therapist removed a vial of sterile water to prepare a nebulizer treatment. As he pierced the vial, he realized the vial was actually Atracurium (a paralyzing agent). The 10 mL Atracurium (Bedford) and sterile water (Abbott) vials have similar purple color accents. Other mix-ups have been attributed to Bedford's atracurium and acetazolamide vials—both have red and white coloring with black print and are packaged in identical sized and shaped vials (see picture 1).
As a further example, Ketoralac and Atracurium are two different medicines with similar lavender labeling and gray snap-off caps (see picture 2). However, as Atracurium is a neuromuscular paralyzing agent, the danger of confusion between these two drugs is of great concern. This problem is discussed in the publication ISMP MEDICATION SAFETY ALERT! Vol. 8, Issue 1 (Jan. 19, 2003).
Another such example is Narcan and Norcuron, which both sound alike when ordered verbally and look alike when handwritten. Confusion between these two drugs can result in serious harm to a patient, as documented in the publication, ISMP MEDICATION SAFETY ALERT! Vol. 3, Issue 20 (Oct. 7, 1998). In that publication, it is noted that a pharmacist misheard a verbal order and dispensed Norcuron, a neuromuscular blocker, when in fact, Narcan was ordered. This resulted in the patient having a respiratory arrest and requiring intubation. Other situations are also documented in this article between these two drugs.
Heparin 10 unit vials and Heparin 10,000 unit vials are also confusingly similar in appearance. The difference in dosage of this blood thinner medication is dramatic and the wrong dosage can be harmful to a patient.
In view of the foregoing discussion, there is a need in the product packaging art for a method and a system that serves to differentiate high-alert medications from other medication products in similarly packaged containers.